Biomedical subjects

Maité Garrouste-Orgeas

Publications and source records attributed to Maité Garrouste-Orgeas.

12 recordsLinked to original sources

PubMed2006

Decision-making process, outcome, and 1-year quality of life of octogenarians referred for intensive care unit admission.

OBJECTIVE: To describe triage decisions and subsequent outcomes in octogenarians referred to an ICU. DESIGN AND SETTING: Prospective observational study in the medical ICU in a tertiary nonuniversity hospital. PARTICIPANTS: Cohort of 180 patients aged 80 years or over who were triaged for admission. MEASUREMENTS: Age, underlying diseases, admission diagnoses, Mortality Probability Model score, and mortality were recorded. Self-sufficiency (Katz Index of Activities of Daily Living) and quality of life (modified Perceived Quality of Life scale and Nottingham Health Profile) were measured 1year after triage. RESULTS: In 132 patients (73.3%) ICU admission was refused, including 79 (43.8%) considered too sick to benefit. Factors independently associated with refusal were nonsurgical status, age older than 85 years, and full unit. Greater self-sufficiency was associated with ICU admission. Hospital mortality was 30/48 (62.5%), 56/79 (70.8%), 9/51 (17.6%), and 0/2 in the admitted, too sick to benefit, too well to benefit, and family/patient refusal groups, respectively; 1-year mortality was 34/48 (70.8%), 69/79 (87.3%), 24/51 (47%), and 0/2, respectively. Self-sufficiency was unchanged by ICU stay. Quality of life (known in only 28 patients) was significantly poorer for isolation, emotional, and mobility domains compared to the French general population matched on sex and age. CONCLUSIONS: More than two-thirds of patients aged over 80 years referred to our ICU were denied admission. One year later self-sufficiency was not modified and quality of life was poorer than in the general population. These results indicate a need to discuss patient preferences before triage decisions.

Aged, 80 and over↗

PubMed2006

Candida colonization of the respiratory tract and subsequent pseudomonas ventilator-associated pneumonia.

BACKGROUND: Recovery of Candida from the respiratory tract of a critically ill patient receiving mechanical ventilation (MV) usually indicates colonization rather than infection of the respiratory tract. However, interactions between Candida and bacteria, particularly Pseudomonas, have been reported. Thus, Candida colonization of the respiratory tract may predispose to bacterial ventilator-associated pneumonia (VAP). METHODS: In a multicenter study of immunocompetent critically ill patients receiving MV for > 2 days, we compared the incidence of pneumonia in patients with and without (exposed/unexposed) respiratory-tract Candida colonization, matched on study center, admission year, and MV duration. RESULTS: Over the 4-year study period, of the 803 patients meeting study inclusion criteria in the six study centers, 214 patients (26.6%) had respiratory tract Candida colonization. Candida albicans was the most common species (68.7%), followed by Candida glabrata (20.1%) and Candida tropicalis (13.1%). Extrapulmonary Candida colonization was more common in exposed patients (39.7% vs 8.3%, p = 0.01). Exposed patients had longer ICU and hospital stays but similar mortality to unexposed patients. The matched exposed/unexposed nested cohort study identified bronchial Candida colonization as an independent risk factor for pneumonia (24.1% vs 17.6%; adjusted odds ratio [OR], 1.58; 95% confidence interval [CI], 0.94 to 2.68; p = 0.0860); the risk increase was greatest for Pseudomonas pneumonia (9% vs 4.8%; adjusted OR, 2.22; 95% CI, 1.00 to 4.92; p = 0.049). CONCLUSIONS: Candida colonization of the respiratory tract is common in patients receiving MV for > 2 days and is associated with prolonged ICU and hospital stays, and with an increased risk of Pseudomonas VAP.

Aged↗

PubMed2005

Predicting whether the ICU can help older patients: score needed.

Because the need for intensive care exceeds its availability in several countries, intensivists must admit those patients most likely to benefit. Intensive care unit admissions of elderly patients will increase substantially in the near future. Decreased self sufficiency and quality of life are common after hospitalization in older patients and they may require discharge to a nursing home, although some patients feel that life in a nursing home would be worse than dying. We have much to learn about matching the use of life-supporting treatments to the health-related values of older patients. A specific outcome-prediction score for older patients would help improve quality of care.

Aged, 80 and over↗

PubMed2005

Risk of post-traumatic stress symptoms in family members of intensive care unit patients.

RATIONALE: Intensive care unit (ICU) admission of a relative is a stressful event that may cause symptoms of post-traumatic stress disorder (PTSD). OBJECTIVES: Factors associated with these symptoms need to be identified. METHODS: For patients admitted to 21 ICUs between March and November 2003, we studied the family member with the main potential decision-making role. MEASUREMENTS: Ninety days after ICU discharge or death, family members completed the Impact of Event Scale (which evaluates the severity of post-traumatic stress reactions), Hospital Anxiety and Depression Scale, and 36-item Short-Form General Health Survey during a telephone interview. Linear regression was used to identify factors associated with the risk of post-traumatic stress symptoms. MAIN RESULTS: Interviews were obtained for family members of 284 (62%) of the 459 eligible patients. Post-traumatic stress symptoms consistent with a moderate to major risk of PTSD were found in 94 (33.1%) family members. Higher rates were noted among family members who felt information was incomplete in the ICU (48.4%), who shared in decision making (47.8%), whose relative died in the ICU (50%), whose relative died after end-of-life decisions (60%), and who shared in end-of-life decisions (81.8%). Severe post-traumatic stress reaction was associated with increased rates of anxiety and depression and decreased quality of life. CONCLUSION: Post-traumatic stress reaction consistent with a high risk of PTSD is common in family members of ICU patients and is the rule among those who share in end-of-life decisions. Research is needed to investigate PTSD rates and to devise preventive and early-detection strategies.

Adult↗

PubMed2005

Predictors of intensive care unit refusal in French intensive care units: a multiple-center study.

OBJECTIVE: To identify factors associated with granting or refusing intensive care unit (ICU) admission, to analyze ICU characteristics and triage decisions, and to describe mortality in admitted and refused patients. DESIGN: Observational, prospective, multiple-center study. SETTING: Four university hospitals and seven primary-care hospitals in France. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Age, underlying diseases (McCabe score and Knaus class), dependency, hospital mortality, and ICU characteristics were recorded. The crude ICU refusal rate was 23.8% (137/574), with variations from 7.1% to 63.1%. The reasons for refusal were too well to benefit (76/137, 55.4%), too sick to benefit (51/137, 37.2%), unit too busy (9/137, 6.5%), and refusal by the family (1/137). In logistic regression analyses, two patient-related factors were associated with ICU refusal: dependency (odds ratio [OR], 14.20; 95% confidence interval [CI], 5.27-38.25; p < .0001) and metastatic cancer (OR, 5.82; 95% CI, 2.22-15.28). Other risk factors were organizational, namely, full unit (OR, 3.16; 95% CI, 1.88-5.31), center (OR, 3.81; 95% CI, 2.27-6.39), phone admission (OR, 0.23; 95% CI, 0.14-0.40), and daytime admission (OR, 0.52; 95% CI, 0.32-0.84). The Standardized Mortality Ratio was 1.41 (95% CI, 1.19-1.69) for immediately admitted patients, 1.75 (95% CI, 1.60-1.84) for refused patients, and 1.03 (95% CI, 0.28-1.75) for later-admitted patients. CONCLUSIONS: ICU refusal rates varied greatly across ICUs and were dependent on both patient and organizational factors. Efforts to define ethically optimal ICU admission policies might lead to greater homogeneity in refusal rates, although case-mix variations would be expected to leave an irreducible amount of variation across ICUs.

Female↗

PubMed2004

Practices in non-neutropenic ICU patients with Candida-positive airway specimens.

OBJECTIVE: To examine practices of French intensivists regarding the management of mechanically ventilated patients with Candida-positive airway specimens but no major risk factors for immunodepression. Design : Closed-item questionnaire with a clinical vignette. SETTING: 564 French intensive care units (ICUs). PARTICIPANTS: 198 intensivists who have a special interest in infectious diseases and who answered the questionnaire (response rate, 35.1%). INTERVENTION: None. MEASUREMENTS AND RESULTS: The respondents recommended bronchoalveolar lavage (62.6% of respondents), protected distal sampling and protected specimen brush (59.1%), transbronchial biopsy (38.9%), and tracheal aspiration (12.1%) for the diagnosis of candidal pneumonia. A positive airway specimen was felt by most respondents (83.3%) to indicate colonisation; 66.7% of respondents recommended tests for systemic candidiasis in this situation, and 56.5% serial sampling to compute the colonisation index. Azole derivatives were the preferred antifungal medications. The clinical vignette described a patient with chronic obstructive lung disease who required mechanical ventilation for an acute exacerbation and who had a tracheal aspirate positive for Candida. Responses varied widely, with 37.8% of respondents diagnosing clinically insignificant colonisation but 24.2% recommending antifungal treatment and 61.6% serial testing to assess the Candida colonisation index. Intensivists with greater experience with severely immunocompromised patients were more aggressive in their diagnostic management. CONCLUSIONS: Wide variations occur among practices of French intensivists regarding Candida-positive airway specimens in patients without major risk factors for immunodepression. Additional studies are needed to improve our understanding of the links between Candida colonisation and infection and to determine the indications for pre-emptive antifungal treatment in non-neutropenic critically ill patients.

Antifungal Agents↗

PubMed2004

Body mass index. An additional prognostic factor in ICU patients.

OBJECTIVE: To examine the association between body mass index (BMI) and mortality in adult intensive care unit (ICU) patients. DESIGN. A prospective multi-center study. INTERVENTIONS: None. METHODS: A cohort study (yielding the OUTCOMEREA database) was conducted over 2 years in 6 medical-surgical ICUs. In each participating ICU, the following were collected daily: demographic information, admission height and weight, comorbidities, severity scores (SAPS II, LOD, and SOFA), ICU and hospital lengths of stay, and ICU and hospital mortality rates. RESULTS: A total of 1,698 patients were examined and divided into 4 groups based on BMI: <18.5, 18.5-24.9, 25-29.9, and >30 kg/m(2). These groups differed significantly for age, gender, admission category (medical, scheduled surgery, unscheduled surgery), ICU and hospital lengths of stay, and comorbidities. Severity at admission and within the first 2 days was similar in the 4 groups, except for the SOFA score. Overall hospital mortality was 31.3% (532 out of 1,698 patients). By multivariate analysis, a BMI below 18.5 kg/m(2) was independently associated with increased mortality (odds ratio 1.63; 95% confidence intervals 1.11-2.39). None of the other BMI categories were associated with higher mortality and even a BMI>30 kg/m(2) was protective of mortality (odds ratio 0.60, 95% confidence intervals 0.40-0.88). CONCLUSIONS: A low BMI was independently associated with higher mortality and a high BMI with lower mortality in this large cohort of critically ill patients. Since BMI is absent from currently available scoring systems, further studies are needed to determine whether adding BMI would improve the effectiveness of scores in predicting mortality.

Aged↗

PubMed2003

Junior versus senior physicians for informing families of intensive care unit patients.

To compare the effectiveness of information delivered to family members of critically ill patients by junior and senior physicians, we performed a prospective randomized multicenter trial in 11 French intensive care units. Patients (n = 220) were allocated at random to having their family members receive information by only junior or only senior physicians throughout the intensive care unit stay; there were 92 and 93 evaluable cases in the junior and senior groups, respectively, with no significant differences in baseline characteristics. Between Days 3 and 5, one family representative per patient was evaluated for comprehension of the diagnosis, prognosis, and treatment in the patient; satisfaction with information and care; and presence of symptoms of anxiety and depression. No significant differences were found between the two groups for any of these three criteria. Family members informed by a junior physician were more likely to feel they had not been given enough information time (additional time wanted: 3 [0-6.5] vs. 0 [0-5] minutes, p = 0.01) and to have sought additional explanations from their usual doctor (48.9 vs. 34.4%, p = 0.004). Specialty residents, if given opportunities for acquiring experience, can become proficient in communicating with families and share this task with senior physicians.

Adult↗

PubMed2003

Decisions to forgo life-sustaining therapy in ICU patients independently predict hospital death.

OBJECTIVE: More than one-half the deaths of patients admitted to intensive care units (ICUs) occur after a decision to forgo life-sustaining therapy (DFLST). Although DFLSTs typically occur in patients with severe comorbidities and intractable acute medical disorders, other factors may influence the likelihood of DFLSTs. The objectives of this study were to describe the factors and mortality associated with DFLSTs and to evaluate the potential independent impact of DFLSTs on hospital mortality. DESIGN AND SETTING: Prospective multicenter 2-year study in six ICUs in France. PATIENTS: The 1,698 patients admitted to the participating ICUs during the study period, including 295 (17.4%) with DFLSTs. MEASUREMENTS AND RESULTS: The impact of DFLSTs on hospital mortality was evaluated using a model that incorporates changes in daily logistic organ dysfunction scores during the first ICU week. Univariate predictors of death included demographic factors (age, gender), comorbidities, reasons for ICU admission, severity scores at ICU admission, and DFLSTs. In a stepwise Cox model five variables independently predicted mortality: good chronic health status (hazard ratio, 0.479), SAPS II score higher than 39 (2.05), chronic liver disease (1.463), daily logistic organ dysfunction score (1.357 per point), and DFLSTs (1.887). CONCLUSIONS: DFLSTs remain independently associated with death after adjusting on comorbidities and severity at ICU admission and within the first ICU week. This highlights the need for further clarifying the many determinants of DFLSTs and for routinely collecting DFLSTs in studies with survival as the outcome variable of interest.

APACHE↗

PubMed2003

Fatal septic shock caused by Corynebacterium D2.

BACKGROUND: Septic shock remains one of the leading causes of mortality in critically ill patients. Optimal management depends on prompt diagnosis with identification of the causative organisms to allow appropriate antibiotic therapy. PATIENT: We report the first case of septic shock caused by Corynebacterium D2, a micro-organism that can cause encrusted cystitis and pyelitis of transplanted kidneys or, more rarely, native kidneys. Diagnosis rests on identification of risk factors, positive urine cultures, and computed tomography results. Despite optimal treatment our patient died with persistent encrusted pyelitis. CONCLUSIONS: Corynebacterium D2 is known to cause chronic inflammation of the bladder and proximal urinary tract but can also cause severe septic shock in immunocompetent patients.

Aged↗

PubMed2003

Triaging patients to the ICU: a pilot study of factors influencing admission decisions and patient outcomes.

OBJECTIVE: To assess the appropriateness of ICU triage decisions. DESIGN. Prospective descriptive single-center study. SETTING: Ten-bed, medical-surgical ICU in an acute-care 460-bed, tertiary care hospital. PATIENTS: All patients triaged for admission were entered prospectively. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Age, underlying diseases, admission diagnoses, Mortality Probability Model (MPM0) score, information available to ICU physicians, and mortality were recorded. Of the 334 patients (96% medical), 145 (46.4%) were refused. Reasons for refusal were being too-sick-to-benefit (48, 14%) and too-well-to-benefit (93, 28%). Factors independently associated with refusal were patient location, ICU physician seniority, bed availability, patient age, underlying diseases, and disability. Hospital mortality was 23% and 27% for patients admitted to our ICU and other ICUs, respectively, and 7.5% and 60% for patients too well and too sick to benefit, respectively. In the multivariate Cox model, McCabe = 1 [hazard ratio (HR), 0.44 (95% CI, 0.24-0.77), P=0.001], living at home without help (HR, 0.440, 95% CI, 0.28-0.68, P=0.0003), and immunosuppression (HR, 1.91, 95% CI, 1.09-3.33, P=0.02) were independent predictors of hospital death. Neither later ICU admission nor refusal was associated with cohort survival. MPM0 was not associated with hospital mortality. CONCLUSIONS: Refusal of ICU admission was related to the ability of the triaging physician to examine the patient, ICU physician seniority, patient age, underlying diseases, self-sufficiency, and number of beds available. Specific training of junior physicians in triaging might bring further improvements. Scores that are more accurate than the MPM0 are needed.

Decision Making↗

PubMed2003

Opinions about surrogate designation: a population survey in France.

OBJECTIVE: Many patients go through periods when they are too ill to give consent or to participate in decisions. When this occurs, patient autonomy is best maintained when a surrogate designated by the patient and familiar with his or her values can speak for the patient. The objective of this study was to determine whether people who are not yet ill are ready to accept surrogate designation. Attitudes toward family participation in care were explored also. DESIGN: Population survey by telephone. Because refusal of life-sustaining treatment is a dramatic example of patient autonomy, the survey used questions about ICU admission. SETTING: General population in France. SUBJECTS: Representative random sample of 8000 residents of France aged 18 yrs or more. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The survey investigated attitudes. RESULTS: Most respondents said they would like to designate a surrogate (7205 [90%]) and to have their family share in their care (6691 [84%] for bathing, 5629 [70%] for feeding, and 4139 [52%] for tracheal suctioning) and in decisions about their management (6120 [76%]). Among respondents with a spouse, 79% said they would designate the spouse to speak for them. The attitudes were not influenced by ethnicity, religion or education level. CONCLUSIONS: Most people living in France would want a surrogate to represent them should they be incompetent and admitted to an ICU. Primary care physicians should inform their patients about the benefits of discussing illness-related issues among friends and family.

Adult↗